Healthcare Provider Details

I. General information

NPI: 1306536461
Provider Name (Legal Business Name): MS. NICOLE BARONE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 SE 182ND AVE
GRESHAM OR
97030-5062
US

IV. Provider business mailing address

4100 SE 182ND AVE
GRESHAM OR
97030-5062
US

V. Phone/Fax

Practice location:
  • Phone: 503-451-3889
  • Fax:
Mailing address:
  • Phone: 503-451-3889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR7782
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: